Coverage Policies

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Current policies effective through April 30, 2024.

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QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



Effective Date: 10/01/2020	Title: Trodelvy (sacituzumab)
Revision Date: 01/01/2021	Document: BI663:00
CPT Code(s): C9066, J9317
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. 1) Trodelvy (sacituzumab) requires prior authorization. 2) Trodelvy is used to treat adults with metastatic triple-negative breast cancer. 3) Trodelvy is a specialty medication covered under the medical benefit.
Medical Statement
Trodelvy (sacituzumab) is considered medically necessary for members meeting all of the following criteria: 1) Diagnosis of metastatic triple-negative breast cancer (mTNBC); 2) Member has received at least two prior therapies for metastatic disease 3) Member is > 18 years of age Initial authorization is for 6 months. Reauthorization (12 months) is approved if documentation provided of tumor response with disease stabilization or reduction of tumor size and spread. Codes Used In This BI: 1) No current specific HCPCS 2) J9317 Injection, sacituzumab govitecan-hziy, 2.5 mg
Reference
1) Trodelvy Prescribing Information. Morris Plains, NJ: Immunomedics, Inc.; April 2020. 2) NCCN Drugs and Biologics Compendium. Accessed online 08-11-2020. Addendum: 1) Effective 01-01-2021: New code J9317- replaces code C9066.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

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